THEY WAY WE WERE

“You will wear this monitor for 30 days, and if you feel anything strange, push this button.”

Thirty days? I thought. After my first episode of palpitations, a 48 hour Holter had been non-diagnostic. A second episode a few months later lasted long enough to obtain an EKG during it and show I was in atrial fibrillation. A mid-level provider reassured me this was not serious. As a neurologist, however, I knew full well (and I knew it before the mid-level was born) that atrial fibrillation is a strong risk factor for stroke. It wasn’t his heart; it was mine. I didn’t see the cardiologist that day, but I did get an appointment for a week later, with one who had seen me before. I’m an established patient—a week is a bit long to wait but acceptable.

My first appointment had been well after my first episode. A then-66 year-old with palpitations ought to be seen quickly, I thought, but It took two weeks to get a Holter monitor and another month to be seen, in part because the referral got lost, and I had to call to find out what was going on. I do wonder what happens to the elderly who aren’t physicians and might not be thinking clearly. Would they ever call? Would anybody notice there was no appointment? We don’t discuss bad system problems when we discuss health care reform. We assume access and dealing with cost is the problem; quality is supposedly a given.

It isn’t.

After my diagnosis was confirmed, the cardiologist told me all the probabilities, gave me a medication if I needed it, and said he didn’t need to see me for a year. OK, I had better than 95% chance (but not better than 97% chance) of doing well.

Twenty days later, I had another episode after a hike, and while I was fine while walking, I was light-headed in the car, so somebody drove me home. I wrote the cardiologist, because we now have e-mail communication. I was called two days later, not from him but from the appointment scheduler, telling me to come in for a monitor. That sounded odd, because I knew what I had. Shortly after, I was discussing a month-long monitor, which had never been mentioned at either of my first two appointments. Worse, it was the wrong kind of monitor for my condition, and that bothered me. The tech was savvy enough to say I could decline the monitor, and she was right. Patients can refuse tests. I could not understand that if my appointment were a year away, why did I suddenly need another test?

The problem was that the cardiologist neither called me nor spoke to me. It appears today that doctors are so busy that patient inquiries are handled by middlemen and middlewomen. That’s a recipe for miscommunication. I think, but don’t know for sure, the cardiologist received a message that I was desperate to know what was going on, which I wasn’t. I was just informing him.

My wife gets after me every time I complain that “medicine isn’t the way it was when I practiced it.” Well, it isn’t. I spent an hour or two a day in practice on the telephone with patients, and these calls were never billed. They were part of giving care. The patients didn’t want to talk to a nurse; they wanted to talk to me. They called about test results, and if I had my staff tell them their test was normal, they still wanted to speak to me. I answered every call the day it was received. I didn’t blow them off.

This is lost, now. Thirty weeks later, I had my fourth episode, followed by my fifth 4 weeks later, both after hikes, both spontaneously converting in 2-3 hours. I e-mailed the cardiologist asking whether I should take the pill or just ride the episode out. I said the problem wasn’t urgent, but the longer the e-mail sits (3 business days is the reply time they say, but it has now been 9), the more likely it is to be forgotten. Why can’t somebody pick up a phone and call me? Or, since we have technology, answer a simple e-mail? We’re talking 30 seconds.

My wife has the same issue. She needed a GI evaluation, and the referral wasn’t successfully transmitted across a street. It was finally hand carried, which I would have done the first time. I used to walk 150 yards to an imaging center to look at my patients’ head scans with a radiologist. It took fewer than 10 minutes, during which I got a great reading, the radiologist loved having clinical information, and I could tell the patient what was occurring, not having them go home to wait 1-2 weeks (or longer) for a report. This is what medicine should be doing. Today, I could pull the scan up in the office and view it myself. I probably could talk to the radiologist at the same time.

My wife had a later reason to call GI and was told she couldn’t see the doctor for five months. She’s an established patient, and five months is unacceptable. She got to talk to a PA who had a 2 month appointment wait. I can’t count how many “Headache, emergency, see today” patients I had to work in to my daily schedule, and they were nearly all tension headaches. Same day service by a specialist. Even a walk-in one day who was a Canadian winter visitor. I discounted the charge on the Canadian, because the problem was simple. Who does that?

My wife got three pages of information what to try. This involved the PA’s talking to the physician and deciding what she had on the basis of second hand communication. Doctor Radio on Sirius XM has better. I am convinced that a good GI physician could deal with her problem in 10-15 minutes. Talking to a physician appears to be closely regulated. If this improves medical care and flow of patients, fine. I’d like to see the data, however.

Fortunately, we still know a physician in Tucson, where my wife frequently goes, who does answer calls. Semi-retired, he is as wise as they come. He’s the kind of doctor I wish I could have been. He’s old style when it comes to seeing people but adept at using technology, so that I could have pictures of my colonic polyps that he removed. When I needed to see him for something else, he sat down in the office and gave me the sense he was there as long as I wanted. He’s great.

If we’re too busy to do it right, then we are too busy. I was too busy, and my only solution was to leave. I think medicine lost something, although some might disagree. Technology is essential in medicine, but the human voice, the human touch, the human approach is also essential. I can’t put a price tag on it.